Therapy of acute basilar artery occlusion: intraarterial thrombolysis alone vs bridging therapy.
OBJECTIVE
While intravenous recombinant tissue plasminogen activator (rt-PA) has been approved for acute stroke therapy within 3 hours, the optimum management of basilar artery occlusion (BAO) is still a matter of debate. We compared intraarterial thrombolysis with the combined bridging approach of intravenous abciximab and intraarterial thrombolysis with rt-PA (bridging therapy) in an observational, longitudinal, monocenter study.


METHODS
Between 1998 and 2006, information for 106 patients with acute BAO were prospectively entered into a local database. Patients eligible for treatment received either intraarterial thrombolysis with rt-PA alone (intraarterial thrombolysis) or were treated with intravenous abciximab and intraarterial rt-PA (bridging therapy). Outcome parameters were recanalization of the basilar artery according to Trial in Myocardial Infarction criteria, survival, and reduction of severe disability and death at 3 months. Logistic regression was used to identify independent predictors for recanalization, survival, and clinical outcome.


RESULTS
Of a total of 106 patients with confirmed BAO, 87 patients underwent subsequent angiography. Among those, 75 patients were identified who received the full treatment protocol. Patients in the bridging group had a better recanalization rate (83.7% vs 62.5%; P=0.03), a higher survival rate (58.1% vs 25%; P=0.01), and a better chance for an outcome with no or only mild to moderate disability (modified Rankin Scale score, 0-3; 34.9% vs 12.5%; P=0.02). Symptomatic intracerebral hemorrhage rates were comparable in both groups (14% in the bridging group vs 18.8%; P=0.41). Independent predictors for recanalization were age (OR, 0.95; 95% CI, 0.91-0.99), atrial fibrillation (OR, 6.53; 95% CI, 1.14-37.49), and bridging therapy (OR, 3.37; 95% CI, 1.02 to 11.18). Independent prognostic factors for outcome were Glasgow coma scale score at presentation (OR, 1.24; 95% CI, 1.03-1.45) and the combination of bridging therapy with successful recanalization (OR, 3.744; 95% CI, 1.04-13.43).


CONCLUSIONS
Bridging therapy for acute BAO with intravenous abciximab and intraarterial rt-PA appears to be safe and yields higher recanalization and improved survival rates, as well as an overall improved chance for a better outcome.
Nagel
Simon
S
Department of Neurology, University of Heidelberg, INF 400, 69120 Heidelberg, Germany. simon.nagel@med.uni-heidelberg.de
Schellinger
Peter D
PD
Hartmann
Marius
M
Juettler
Eric
E
Huttner
Hagen B
HB
Ringleb
Peter
P
Schwab
Stefan
S
Köhrmann
Martin
M
D000077284:Abciximab; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000911:Antibodies, Monoclonal / Q000008:administration & dosage*; D001488:Basilar Artery / Q000000981:diagnostic imaging / Q000187:drug effects / Q000473:pathology; D003952:Diagnostic Imaging; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000008:administration & dosage*; D007261:Infusions, Intra-Arterial / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D007275:Injections, Intravenous / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D011446:Prospective Studies; D011859:Radiography; D020127:Recovery of Function / Q000187:drug effects / Q000502:physiology; D015996:Survival Rate; D015912:Thrombolytic Therapy / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome; D014715:Vertebrobasilar Insufficiency / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology; D055815:Young Adult
D000911:Antibodies, Monoclonal; D005343:Fibrinolytic Agents; D007140:Immunoglobulin Fab Fragments; D010975:Platelet Aggregation Inhibitors; D010959:Tissue Plasminogen Activator; D000077284:Abciximab